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Rehabilitation Prescriptions: Are Stroke Survivors Being Let Down?

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Tom Balchin - stroke survivor and founder of Action for Rehabilitation from Neurological Injury

In 2010, the Clinical Advisory Group recommended every patient admitted to a Major Trauma Centre ought to have a rehabilitation prescription documenting their rehabilitation needs. Eleven years on, rehabilitation prescriptions are not used effectively and uniformly, to the detriment of patients and those who support them.

Tom Balchin is the founder of Action for Rehabilitation from Neurological Injury (ARNI) who had a haemorrhagic stroke when he was 21. For over 20 years, Tom has committed his life to helping stroke survivors make a functional recovery through a specialist rehabilitation programme that he developed based on his own experience. The ARNI programme is backed by clinical studies and Tom’s methods are endorsed by senior doctors.

Here, Tom talks about his experience with rehabilitation prescriptions and, if used properly, how it could benefit stroke survivors.

What is a rehabilitation prescription?

The idea of a rehabilitation prescription came out of Trauma Services a decade ago. During this time, there was a growing realisation that as patients moved between stages of recovery in acute centres to community rehabilitation, there was frequently a steep fall-away of information available to professionals and patients. This information is deemed to be essential to guide a patient’s rehabilitation to achieve the best outcome.

The rehabilitation prescription should identify the rehabilitation needs and how these needs will be met. It should be started within three days of admission to a Major Trauma Centre by a suitably qualified member of the rehabilitation team, usually a Band 7 physiotherapist. The rehabilitation prescription should be reviewed regularly and kept up to date.

What information should be in a rehabilitation prescription?

From a patient’s point of view, the main focus of a rehabilitation prescription is to document rehabilitation needs and to plan treatment to meet those needs. Neurorehabilitation is multidisciplinary. Core specialties include physiotherapy, occupational therapy, neuropsychology, and speech and language therapy.

The rehabilitation prescription ought to contain information on different aspects of recovery including:description of injuries/illness, psychosocial background, treatment received, clinical restrictions and individual rehabilitation needs.

There should be sufficient information for each specialist in the multidisciplinary team to plan and deliver ongoing rehabilitation to maximise the potential for an optimal outcome.

Who should receive a rehabilitation prescription?

The patient and/or family, as well as their GP, should receive a copy.

However, as Professor Mike Barnes, ABI Alliance Chair, has rightly noted: ‘the rehabilitation prescription has no value if the individual with an acquired brain injury and their GP don’t receive a copy. If the individual and the GP don’t know what rehabilitation is preferably required, then no access to services can be planned or implemented’.

There is a feeling, clinically and in the community, that the use of rehabilitation prescriptions is sporadic.

Why are rehabilitation prescriptions important for stroke survivors?

When the patient reaches the community, outside of the realm of NHS help, a rehabilitation prescription that can be used to guide ongoing rehabilitation is ideal. Some patients, or most often their families/carers, are very careful to keep as much information as they can.

Unfortunately, patients often seem to travel away from the clinical remit without copies of discharge notes and with no guidance about ‘what to do’ when they return home.

Especially during this pandemic, when disruption to health and care services has meant that national stroke initiatives across the country have been paused or slowed, it’s not surprising this is the case.

With innovative solutions being implemented to tackle disruption to stroke services, are rehabilitation prescriptions as important as ever or not?

Rehabilitation prescriptions would seem to be even more important during this pandemic.

This is because for patients who have gone without, or had very little therapy, and have the means to afford private support, a rehabilitation prescription would be ideal to guide an independent therapist or trainer.

A Stroke Association survey last year of almost 2,000 survivors makes interesting reading. The number of stroke survivors who had therapy cancelled or postponed was very high – 44 per cent had appointments related to their stroke online or over the phone during the pandemic and 28 per cent had therapy online or by phone.

Unfortunately, virtual methods of healthcare have not been viable for all. The number of stroke survivors who had therapy cancelled or postponed is double the number who received therapy online or over the phone pre-pandemic.

This shows that many have not had their usual rehabilitation support, but with a rehabilitation prescription, would at able possibly to have been supported into some kind of community-run therapy, possibly delivered by the third sector.

What is your experience with rehabilitation prescriptions in stroke survivors?

They basically don’t happen. Even now, senior clinical therapists around the country have only heard rumours about them being created and are not clear what form these would take.

I spoke with Avril Drummond, Professor of Healthcare Research at Nottingham University, about rehabilitation prescriptions for stroke survivors.

Professor Drummond is well versed in the national situation and forthcoming initiatives in stroke. After enquiring with colleagues for a few weeks about rehabilitation prescriptions for stroke survivors she ‘drew a total blank’.

Further questioning to the National Leads revealed they ‘don’t know’. If the National Leads don’t know, then we can be quite sure nothing is going to take place on this any time soon. This is a shame because it would be invaluable for a patient to know any trainer or therapist they work with can access to a simple ‘passport’ containing up to date information on their rehabilitation needs.

Ideally, a rehabilitation prescription would be updated as a patient advances in their life after stroke. The rehabilitation prescription would be accessible by other rehabilitation professionals. Assisting professionals is essential to achieving the best outcome in the most efficient way.

What is required to ensure rehabilitation prescriptions are used effectively?

There needs to be a comprehensive national rehabilitation strategy to roll-out rehabilitation prescriptions as a requirement to give to patients and professionals. This would provide clear information to refer to as patients move from acute services to community services and beyond.

Tom Balchin is founder of The Arni Institute – for more information, visit www.arni.uk.com. He was speaking with Hokman Wong, senior solicitor at law firm Bolt Burdon Kemp and a specialist in adult brain injury claims.

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Robot with ‘potential to redefine neurorehab’ unveiled by Fourier

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A robotic rehab device hailed as being instrumental in changing the future of neurorehabilitation has been unveiled to the world by Fourier Intelligence, after more than two years in development. 

The ArmMotus™ EMU is the world’s first 3D back-drivable upper limb rehabilitation robot, setting a new benchmark for intelligent rehabilitation devices. 

The robot, the latest world-leading addition to Fourier Intelligence’s portfolio, is said to have the potential to redefine human-machine interaction. 

It is the first of its kind that applies the end-effector based concept into the 3D movement, bringing a new experience of robotics rehabilitation therapy. 

The product – revealed during RehabWeek 2021 – revolves around a cable-driven mechanism, that combines with a four-linkage structure, which reduces the friction and inertia during the movement of the system. This design also enables the control system to respond and execute more efficiently.

Zen Koh, co-founder and Global Hub CEO of Fourier IntelligenceZen Koh, co-founder and Global Hub CEO of Fourier Intelligence, hailed the robot as helping to redefine the future. 

“Current neurorehabilitation models primarily rely on extended hospital stays or regular therapy sessions which require close physical interactions between rehab professionals and patients,” he said. 

“The ongoing COVID-19 pandemic situation has challenged this model and as a result, many neurological patients are not receiving sufficient therapy. There is an urgent need to rethink conventional neurorehabilitation therapy.

“The new ArmMotus™ EMU provides that solution. The EMU, equipped with clinical intelligence, provides personalised therapy, technology-based solutions, coaching capabilities and remote monitoring.

“The implementation of fun functional games with embedded artificial intelligence also provides clinically motivating therapy to patients as well as giving caregivers and healthcare practitioners confidence.”Professor Denny Oetomo

The ArmMotus™ EMU, jointly built by Fourier Intelligence and the University of Melbourne Robotics Laboratory, has taken two years to bring to fruition and was led by Professor Denny Oetomo. 

“The robot offers large workspace with very minimal resistance and reflected inertia of the robot on the patient. This would allow the patient to move freely”, said Prof Oetomo.

“Combined with the appropriate gravity compensation of the weight of the arm, patients with weak or little arm function, is able to carry out therapy without exertion.”

Another key person to the success of the ArmMotus™ EMU, Dr Marlena Klaic, the translational research lead at Royal Melbourne Hospital, gave further insight into why robotic rehabilitation is important. 

“There’s a large and growing body of evidence suggesting that robotic devices can improve a patient’s outcome, including function, strength and ADL,” said Dr Klaic. 

“This evidence is growing even more rapidly in these pandemic times as more people are exploring digital and remote prevision therapies.

Dr Marlena Klaic, the translational research lead at Royal Melbourne Hospital“We conducted a user-based design study where we build and modify the robot based on the feedback from clinicians. Based on our results, we found that clinicians believe that robotic devices can be helpful in their practice. Patients and junior therapists are more frequently asking for robotic devices as part of their therapy session.”

Aside from exoskeleton and other one-dimension upper limb rehabilitation robots, EMU is based on terminal control and high technical content which is difficult to develop. It is China’s first breakthrough in this field. 

EMU uses the industry-leading force feedback technology platform, which was independently developed by Fourier Intelligence, to simulate the force exerted by a therapist. It also provides a large 3D trajectory training space which allows rehabilitation movements to be more realistic and guides users to complete various complex rehabilitation training.

Product director of Fourier Intelligence, Daris Yang, also explained the importance of having interactive rehabilitation programmes. 

“By equipping EMU with games such as table tennis, cooking, and fishing, this would simulate activities of daily living even more,” said Yang. 

“The boring and repetitive training actions in traditional rehabilitation makes it boring for patients to train for a long time. Our EMU game settings have completely rewritten the rehabilitation scene.”

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Brain Bank spearheads quest for CTE cure by 2040

Sportspeople are urged to play their role in making sport a safer place, as well as to follow the lead of Steve Thompson MBE in donating their brains to research

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Professional sportspeople were today urged to play their role in making sport safer as a pioneering project was announced with the aim of preventing new cases of Chronic Traumatic Encephalopathy (CTE) within five years and of finding a cure by 2040. 

The internationally-renowned Concussion Legacy Foundation has now come to the UK, following 14 years of research and advocacy that has led to change in sport, and support of players, around the world. Its founder, Dr Chris Nowinski, was instrumental in forcing NFL to change its protocols around head injury through his 2006 book ‘Head Games: Football’s Concussion Crisis’. 

And through the creation of the Concussion Legacy Project, a new brain bank in partnership with the Jeff Astle Foundation, it hopes to gather more vital research in this area to protect future generations of sportspeople.

England Rugby World Cup winner Steve Thompson MBE announced he had become the first donor to the Project. 

And Dr Nowinski called on sportspeople to take the lead in making sport a safer place for themselves, their teammates and future generations, as he bids to eradicate CTE. 

Research has shown CTE develops through repeated hits to the head over a period of time, which can begin in childhood in many instances. 

“This is the time for professional sports men and women to step up and join the fight to change the game, reduce the risk of CTE, change your destiny,” he told a press conference. 

“Make no mistake – some of you already have CTE and every header or tackle will be making it worse. You will have teammates who will have, or will develop, CTE. 

“Step forward and make a positive difference. Take advantage of this opportunity before it’s too late. It is too late for heroes like Jeff Astle and Rod Taylor, but it’s not too late for our children.”

Dr Nowinski, who is an advocate of non-contact sport until at least the age of 14, reiterated his fears for children if action is not taken now. 

“We should not be giving children a preventable brain disease before they are old enough to drive, vote, or take many decisions for themselves,” he said. 

“We need to stop hitting children in the head, we are giving them a life-long brain disease. The only way we know to prevent CTE is to limit the exposure to head impact and we have to do that.”

Dr Adam White was announced as executive director of the newly-created Concussion Legacy Foundation UK.

“We’ve long known about the relationship between sport and CTE, but we urgently need to better understand how CTE affects athletes and veterans, as well as their families, at every stage of their life,” said Dr White. 

“We have reason for hope. CTE usually begins in a person’s teens or twenties, which means we have a lifetime to treat patients, educate people and support their families. 

“We want to stop all new cases of CTE in the next five years and have a cure by 2040.”

Appeals were also made for sportspeople to donate their brains to the Concussion Legacy Project, following the brave lead of Steve Thompson. 

The project builds on the lead of the VA-BU-CLF Brain Bank in Boston, which has created the world’s leading CTE research program. To date, more than 1,000 brains have been donated and 600 cases of CTE diagnosed, which comprises about 80 per cent of the world’s confirmed cases.

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“I’m pledging my brain so the children of the people I love don’t have to go through what I have gone through,” said the former British Lion who was diagnosed with dementia at the age of 42. 

“It’s up to my generation to pledge our brains so researchers can develop better treatments and ways to make the game safer.”

“Brain donation is the most valuable gift of all for future generations of footballers,” said Dawn Astle, daughter of Jeff Astle. 

“It may be many years before this jigsaw is complete, but by adding each piece, one at a time, it is the only way we shall understand the true picture and so be able to make a better future for others. 

“The Jeff Astle Foundation encourages families of athletes and veterans to donate the brain of their loved one to the Concussion Legacy Project.”

The Concussion Legacy Project will be led by Dr Gabriele DeLuca, associate professor in the Nuffield Department of Clinical Neurosciences, University of Oxford, and director of clinical neurosciences undergraduate education at Oxford Medical School.

“Brain donation will allow us to better understand the complexities of CTE so that we can develop tailored interventions and treatments to prevent its devastating consequences,” said Dr DeLuca. 

In the next phase of the collaboration, Dr. DeLuca will lead clinical research efforts aimed at learning how best to treat common CTE-related symptoms, including problems with thinking and memory, mood, and sleep.

Athletes and veterans can pledge to donate their brains to CTE research at PledgeMyBrain.org.

The Concussion Legacy Foundation UK has created a 24-hour brain donation hotline for families to call and coordinate brain donations. Family members of athletes and military service members who wish to donate their loved one’s brain can contact the Concussion Legacy Project at 07534 029 223 and UK@concussionfoundation.org.

 

 

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Sexual trauma ‘could lead to neurological conditions’

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Traumatic experiences, including sexual violence, could be linked to dementia, stroke and other brain disorders in women, new research has indicated.

Links between such trauma and poor mental and cardiovascular health are already established – but a new study suggests they could also be linked to indicators of cerebrovascular risk that may be a precursor to neurological conditions. 

To date, little research has been done to examine the relationship between traumatic experiences, including sexual assault, and indicators of small vessel disease in the brain. 

But a new study from the University of Pittsburgh specifically investigated whether traumatic experiences were associated with white matter hyperintensities (WMHs), which are markers of brain small vessel disease. 

WMHs can be detected decades before the onset of dementia, stroke, and other neurological risk and can serve as early markers. 

Of the nearly 150 mid-life women involved in the study, 68 per cent reported having at least one trauma, with the most common trauma being sexual assault (23 per cent of the women). 

After evaluating the data, researchers concluded that women with trauma exposure had greater WMH volume than women without trauma. The particular trauma significantly associated with WMH was sexual assault.

Associations between sexual assault and WMHs persisted even after adjusting for depressive or post-traumatic stress symptoms, suggesting that sexual assault may put women at greater risk for poor brain health.

“The results of this study are noteworthy in that sexual assault is an unfortunate, yet all-too-common, experience for women; national data indicates that, on average, up to a third of women have had this experience,” says Dr Rebecca Thurston from the University of Pittsburgh and lead author of the study.

“This distressing experience is not only important for women’s mental health, but also their brain health. This work is a major step toward identifying a novel risk factor for stroke and dementia among women. 

“Not only do these results underscore the need for greater prevention of sexual assault, but also provide healthcare professionals with another indicator of who may be at most risk for stroke and dementia later in life.”

“Identifying early warning signs of stroke and dementia are critical to providing effective intervention,” says Dr. Stephanie Faubion, North American Menopause Society (NAMS) medical director. 

“Studies like this one provide important information about the long-term effects of traumatic experiences on a woman’s overall well-being and mental health.”

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